Presentation of breast disease


  1. Breast lump (painful vs painless)
  2. Pain with no lump (cyclical vs non-cyclical)
  3. Nipple changes or discharge


Approach to breast lump


Differentials


Painless lump
Painful lump
  1. Carcinoma
  2. Cyst
  3. Fibroadenoma
  4. Area of fibroadenosis (nodularity)
  1. Area of fibroadenosis
  2. Cyst
  3. Abscess (usually in lactating women)
  4. Galactocoele (lactating women)
  5. Periductal mastitis
  6. Fat necrosis
  7. Carcinoma (rare; 10% present with pain)




History


  1. History of lump


  • Site of the lump? Single or multiple?


  • When was it first noticed? Why was it noticed (pain, self-examination, etc)?


  • Duration since first noticed


  • Painful or painless?


  • Overlying skin changes noted: erythema, warmth, dimpling, swelling? Any general asymmetry of the breasts noticed?


  • Any increase in size from first noticed to now?


  • Any changes in the nipple e.g. retraction


  • Nipple discharge? If present, what is the colour and consistency?


  • Any other lumps elsewhere – other breast? Axilla? Neck?


  1. Oestrogen exposure history and other risk factors for cancer


  • Age of menarche (early menarche <12 years old increased risk)


  • Whether married, and if married, how many children (nulliparity)


  • Age at which first child was born (>30 years old)


  • Whether patient breastfed her children, and if so, for how long after birth


  • Is patient currently postmenopausal? If so, how old was she when she became menopausal? (>55 years old)


  • Use of hormonal replacement therapy and/or oral contraceptive pills


  • Family history of breast cancer or ovarian cancer (BRCA gene) especially if cancer occurs in first degree relative below the age of 40, or in bilateral breasts


  • Previous breast cancer that has been treated


  • Previous biopsy of the breast showing atypical ductal hyperplasia or LCIS


  • Exposure to ionising radiation


  • Alcohol intake, especially before age of 30


  1. Systemic review
  • Loss of appetite, loss of weight
  • Fever (infective cause)
  • Bone pain (metastasis)


Physical examination


Preliminaries


  • Introduce yourself to the patient, ask for permission to examine the breast


  • Always have a chaperone to accompany you if you are male


  • Expose patient adequately from the waist up with exposure of axillae


  • Good lighting


  • Position the patient at 45 degrees or sitting position if a bed is not available


Inspection


  • Start off with patient’s hands relaxed at her sides – look for any asymmetry in the breast contours, any obvious skin changes (peau d’orange, erythema, puckering)


  • Look for any scars of previous operation, or procedure e.g. punch biopsy


  • Then ask patient to raise her arms (to accentuate any tethering to the skin which shows up as dimpling)


  • Ask the patient to push her hands against her hips to contract the pectoralis major muscles – this may reveal a previously unnoticeable lump


  • Look for nipple changes (7 D’s):
  • Discolouration
  • Discharge


  • Depression (retraction)
  • Deviation
  • Displacement
  • Destruction
  • (Duplication – unlikely)
Palpation


  • Patient should be lying down at 45 degrees to the horizontal with her hand tucked behind her head – this splays the breast out so it can be palpated properly


  • Start with the normal side first!


  • Ask for any pain before starting to palpate


  • Use one hand to retract and stabilise the breast and palpate with the other


  • Palpate in a systematic manner e.g. quadrant by quadrant from centre outwards


  • Be thorough and examine the entire breast including the axillary tail


  • When the lump is located, check with the patient whether this is the same lump she detected on her own


  • Characterise the lump:
    • Site (which quadrant)
    • Tender or non-tender
    • Warmth of overlying skin
    • Size
    • Shape
    • Surface (smooth or nodular/irregular)
    • Consistency (soft, firm, or hard)
    • Fluctuance
    • Margins (regular and smooth, or irregular and ill-defined)
    • Fixation to the skin – try to pick up the skin above the lump
    • Fixation to underlying muscle – ask patient to press her hands against her hips to contract the pectoralis major muscle, then try to move the lump in 2 perpendicular directions, then ask patient to relax and try to move the lump again


  • Don’t be happy just finding one lump, still examine carefully for other lumps (multiple lumps are unlikely to be malignant, usually fibroadenoma or fibroadenosis)


  • If the patient complains of nipple discharge and none is visible, ask patient if she can show you the discharge by expressing it herself (NEVER squeeze the nipple yourself!); if patient cannot do it, then ask the chaperone to help


Axillary lymph nodes


  • Palpate the normal side first


  • Rest the patient’s right forearm on your right forearm and use your left hand to palpate the right axilla (vice versa for the left side)


  • Palpate gently, slowly, and systematically, covering the major groups of nodes: anterior, posterior, medial, lateral, and apical


  • If any lymph nodes are found to be enlarged, note the number of lymph nodes, their site, size, tenderness, consistency (firm, hard, matted), mobility


To complete the examination


  • Examine the cervical lymph nodes especially the supraclavicular nodes


  • Examine the lungs for any pleural effusion


  • Percuss the spine for bony tenderness


  • Examine the abdomen looking for hepatomegaly


Findings for the common breast lumps


Type of lump
Age
Pain
Surface
Consistency
Mobility
Cyst
30-55
Occ
Smooth
Soft to hard
Not fixed
Nodularity
20-55
Occ
Indistinct
Mixed, fluctuant
Not fixed
Fibroadenoma
15-25
No
Smooth, bosselated
Rubbery
Very mobile
Cancer
35+
No
Irregular
Stony hard
May be tethered or fixed


Investigations


The evaluation of a breast lump is via the TRIPLE ASSESSMENT – (i) Clinical examination; (ii) Imaging; and (iii) Histology.”


Imaging


  1. Mammography
  • Most sensitive of the proven breast imaging modalities
  • Usually performed in older women (>40 years old) as the breast tissue in younger women is denser, more difficult to pick up abnormalities on mammogram
  • Normally, 2 views are done: craniocaudal (CC) and mediolateral oblique (MLO)
  • Additional specialised views: magnification and coned compression; done on request to help magnify areas of abnormality or help visualise breast better


  • Abnormal features:


  1. Neo-density or asymmetric density


  1. Microcalcifications
  • Calcifications <0.5mm in size (if >0.5mm macrocalcifications)
  • Sole feature of 33% of cancers detected on mammography
  • Causes: DCIS, invasive cancer, fibrocystic disease, papilloma
  • Features of malignancy: pleomorphic microcals, heterogeneous appearance, closely grouped or arranged in a linear pattern (ductal distribution), underlying density
  • Benign microcals are punctate, and may have a “tea-cup” appearance


  1. Spiculated mass or stellate lesion
  • 95% of spiculated masses on mammography are due to malignancy
  • Stellate lesion is a localised distortion of the breast parenchyma without perceptible mass lesion – high chance of it being malignant
  • Causes: Invasive cancer, radial scar (a benign lesion), fat necrosis, abscess, etc


  1. Architectural disortion


  • Look at the axilla on the MLO view for any enlarged lymph nodes


  • BI-RADS (Breast Imaging Reporting and Data System) classification
Category 0: Need additional imaging evaluation
Category 1: Negative (nothing to comment on, 0.05% risk still present)
Category 2: Benign
Category 3: Probably benign, short-term follow-up suggested (<0.2% risk)
Category 4: Suspicious, biopsy should be considered (25-74% risk)
Category 5: Highly suggestive of malignancy (75-99% risk)
Category 6: Known malignancy


  1. Ultrasound
  • Usually used as the first investigation in young patients (<35 years old) or pregnant, lactating patients
  • Can be used to guide interventional procedures such as biopsy, localisation of a lump preoperatively, drainage of abscess, aspiration of cyst
  • Evaluates consistency (solid vs cystic), margins
  • Localisation of lesion seen in only one mammographic projection
  • Evaluation of a palpable mass with a negative mammogram
  • Evaluation of mass in mammographically-difficult areas e.g. chest wall, axilla
  • Pitalls: Operator dependent, non-standardised techniques, poor resolution, “partially blind” to microcalcifications
  • Features of malignancy:
    • Markedly hypoechoeic + thick echogenic halo
    • Irregular edges
    • Hypoechoeic shadowing
    • Taller than it is wide (fir-tree appearance)
    • High central vascularity


  1. MRI of the breast
  • Rarely used due to high cost, but provides good soft tissue definition
  • Indications:
  • Positive axillary lymph node but mammogram and ultrasound negative
  • Suspicion of multifocal or bilateral malignancy (esp ILC which has a high incidence of multifocality/bilaterality)
  • Assessment of response to neoadjuvant chemotherapy
  • When planning for breast conservation surgery
  • Screening in high-risk patient?
Histology


  • Options available:
  1. Fine needle aspiration cytology
  2. Core biopsy (Trucut)
  3. Incisional biopsy
  4. Excisional biopsy


  • Mostly a choice between FNAC and core biopsy


    • FNAC is less invasive, less painful, smaller wound, does not require any local anaesthetic, but only cells are obtained with no histology cannot differentiate between in-situ cancer and invasive cancer, requires skilled cytopathologist


    • Core biopsy is more invasive, requires local anaesthetic, will result in a larger wound, more painful, risk of complications higher (because biopsy needle is a spring-loaded firing mechanism, improper angling may result in puncture of the lung or heart), but can obtain tissue specimen, can stain for ER/PR status better diagnostic value


  • Can be guided by clinical palpation (if there is a palpable mass) or radiologic guidance if the mass is small or there is no palpable mass more accurate but still not 100%
  • Ultrasound guidance
  • Stereotactic guidance (stereotactic mammotome)


Management


  • If triple assessment suggests benign disease (i.e. all three aspects suggest benign nature of lump), follow patient up with physical examination for a year (q3-6mths) to make sure the lump is stable or regresses


  • If all three aspects of triple assessment suggest malignancy further staging and treatment


  • If one or two out of three aspects suggest malignancy further workup, may require excisional biopsy